A Tumour in the Windpipe or Main Airway
Can It Be Removed?

Why is a tumour in the airway treated differently
from one in the lung?

A tumour in the lung tissue is removed by taking out the piece of lung around it. A tumour in the windpipe (trachea) or a main airway (bronchus) sits in a tube that air has to pass through, so the first problem it causes is obstruction: breathlessness, a cough that sounds different, noisy breathing, repeated infections behind the blockage, or coughing up blood. Treatment therefore has two aims that are decided separately: clearing the airway so that you can breathe, and removing or controlling the tumour itself.

The airway can be reached from the inside. A bronchoscope passed through the mouth under general anaesthetic reaches the windpipe and the main airways directly, so a tumour growing into the airway can be treated without any incision. Where the tumour has grown through the airway wall, or where the type of tumour means it should be removed completely with a margin, the airway segment itself can be removed by an operation and the two healthy ends joined.

Several different tumours grow in the airway. Lung cancer can grow into a main bronchus. Carcinoid tumours, adenoid cystic carcinoma and mucoepidermoid carcinoma arise in the airway itself and some are slow growing. Cancers from elsewhere in the body occasionally spread to the airway wall. The type decides the treatment, which is why a tissue sample and a CT come first. Symptoms that bring patients to this page are covered on the coughing up blood, breathlessness and persistent cough pages.

“I was told it cannot be removed.”
What does that usually mean?

It usually means one of four things: that the tumour cannot be removed by the operation the patient was assessed for; that the centre does not perform airway surgery or interventional bronchoscopy; that a stent was considered and judged too risky for that airway; or that the cancer has spread and removing the airway part would not change the outcome. Only the last of these is a reason to do nothing about the airway, and even then the blockage itself can usually be relieved.

Airway tumours are uncommon and are treated at a small number of centres, so the advice a patient receives reflects what is available where they were seen. Dr Okiror leads the Central Airways Service at Guy’s and St Thomas’, where rigid and flexible bronchoscopy, laser, cryotherapy, stenting and open airway surgery are provided by the same surgeon. Patients whose regional centre has advised against a stent, or against any treatment, are assessed on their own CT and bronchoscopy. Sometimes the original advice is confirmed, and the reasons are given in writing. Sometimes a treatment is available that was not offered.

If the reason given was that the tumour is lung cancer and surgery is not an option, the told surgery is not an option page explains what each of the usual reasons means and which of them can be tested. A second opinion is given on the images, by video if you are not in London.

What can be done
through the bronchoscope?

A tumour growing inside the airway is removed or reduced through a bronchoscope under general anaesthetic. Dr Okiror uses a combination of laser, cryotherapy and mechanical removal, choosing according to the tumour and the airway. Where the airway wall is weakened or the tumour presses on it from outside, a stent is placed to hold the airway open. Diagnosis, treatment and stenting are done under one anaesthetic where that is appropriate, using rigid and flexible bronchoscopes as the case requires.

Clearing the airway relieves breathlessness, cough and bleeding. Whether it also deals with the tumour depends on what the tumour is. For a slow-growing tumour confined to the inside of the airway it may be enough, with follow-up bronchoscopy. For a tumour that has grown through the wall, or for lung cancer growing into a bronchus, it is often the first step before an operation, chemotherapy, immunotherapy or radiotherapy. The clinician-facing detail of the service is on the central airway interventions page.

When is an operation the answer?
Sleeve and tracheal resection

An operation is the answer when the tumour needs to be removed completely with a margin of healthy tissue and that cannot be done from inside the airway: a carcinoid or adenoid cystic carcinoma growing through the wall, or a lung cancer sitting where a main airway joins the lung. The operation removes the segment of airway containing the tumour and joins the two healthy ends together, so that the lung beyond is kept rather than removed. This is a sleeve resection.

Dr Okiror performs bronchial sleeve resection with or without lung resection, sleeve lobectomy (a lobe of lung with its airway, the alternative to removing the whole lung), sleeve resection of the windpipe, and arterial and double sleeve resections where the artery is involved as well as the airway. Most are done through an open approach; some are done robotically. In every sleeve case he examines the airway with a bronchoscope at the start of the operation, during it and at the end, under the same anaesthetic. The operations are described on the sleeve resection page.

Where a tumour sits at the point where the two main airways divide, or would need the whole of the airway junction to be rebuilt, a different operation is needed and Dr Okiror refers to the colleagues who perform it. That is stated at the consultation rather than discovered later.

What if the tumour has come back
after surgery, chemotherapy or radiotherapy?

A tumour that has returned in the airway after earlier treatment can still be treated. Bronchoscopic clearance does not depend on what treatment came before, so an airway blocked by recurrent tumour can be opened with laser and cryotherapy, and a stent placed, whether or not the patient has had radiotherapy or chemotherapy. Whether a further operation is possible is assessed separately, on a new CT and PET-CT and a fresh tissue sample.

Recurrence at the join after a previous sleeve resection, in the remaining airway after a lobectomy, or in the airway after radiotherapy each raise different questions, and they are covered on the lung cancer returning after surgery and surgery after radiotherapy pages. A sample is taken before any decision, because a shadow on a scan after radiotherapy is not always tumour.

Which rare tumours
grow in the airway?

Three tumours arise in the airway itself. Carcinoid tumours are slow growing in most cases and are usually cured by removing the segment of airway or lung they sit in, keeping as much lung as possible. Adenoid cystic carcinoma grows along the airway wall beneath the surface, further than it appears on the scan, so the margin of airway removed matters and radiotherapy sometimes follows. Mucoepidermoid carcinoma has a low-grade form that is cured by removal and a high-grade form that behaves like lung cancer. Cancers from elsewhere in the body, such as the kidney or bowel, occasionally spread to the airway wall and are cleared through the bronchoscope.

Because these tumours are rare, many hospitals see only a few. Each is set out, with what the operation involves and what the follow-up looks like, on the rare lung and chest tumours page.

What if the windpipe collapses
when I breathe out?

In tracheomalacia and excessive dynamic airway collapse (EDAC), the windpipe or main airways narrow or close when you breathe out or cough, instead of staying open. It causes breathlessness on exertion, a harsh barking cough, difficulty clearing phlegm and repeated chest infections, and it is often mistaken for asthma or COPD for years. It is diagnosed on a CT scan taken while breathing out and confirmed at bronchoscopy, where the collapse can be seen directly.

There are three approaches, chosen for the individual patient. CPAP, a mask that holds the airway open with air pressure, is an option. Some patients are treated with an airway stent that holds the collapsing segment open. Some have a temporary stent for four to six weeks: after it is removed the airway sometimes keeps its shape, which avoids the problems of a stent left in long term, where tissue grows around it and bacteria settle on it. Which approach is right depends on where and how much the airway collapses, on symptoms, and on the patient’s other conditions.

Patients whose regional centre has advised against stenting, for example because the windpipe is wide or the segment is long, are assessed on their own CT and bronchoscopy. Some are stented and do well; some are advised against it here too, with the reasons given. A referral from your respiratory physician is welcome but not required.

What tests are needed
before a decision?

Two things: a CT scan of the chest and a bronchoscopy. The CT shows where the tumour is, how much of the airway it involves, whether it has grown through the wall and what lies beyond the blockage; for airway collapse it is taken while breathing out. The bronchoscopy shows the tumour directly and provides the tissue sample. In most patients the bronchoscopy that confirms the diagnosis is the same procedure that treats the obstruction, under one anaesthetic.

If you have already had a CT or a bronchoscopy elsewhere, the images are what Dr Okiror needs, not the report alone. Your hospital can share them to London Bridge Hospital’s imaging system, or give you a link to pass on. For lung cancer a PET-CT and lung function tests are added, as for any lung operation; the tests and staging page explains each.

Lung cancer cases are discussed at the London Bridge Hospital chest multidisciplinary team meeting, which Dr Okiror attends fortnightly. Where a blocked airway cannot wait for the next meeting, he has direct access to the same colleagues between meetings, and the airway is dealt with first.

How quickly can it be done,
and what does it cost?

Appointments are within 2 to 3 days at London Bridge Hospital. Treatment is usually within a week of completing investigations; patients who already have their CT can be booked within days of the consultation, and urgent cases within 48 hours. A patient who is struggling to breathe should go to an emergency department. A patient who arrives at the London Bridge Hospital urgent care centre is admitted directly to the ward, and the airway is treated within 48 hours.

A new consultation is £250–£350. A diagnostic bronchoscopy at London Bridge Hospital is £3,600–£4,500, covering hospital, surgeon and anaesthetist fees. For a treatment bronchoscopy with laser, cryotherapy or a stent, and for sleeve or tracheal resection, the hospital issues a written quote after the consultation, and that quote is the figure that applies. Hospital charges are the largest part of every total. All guide prices and how fees work →

Dr Okiror is recognised by AXA Health, Bupa, Aviva, Vitality, WPA and Cigna, and by most other UK and international insurers. Insurers usually settle the hospital, surgeon and anaesthetist fees in full, less any excess written into the policy. Self-paying patients are equally welcome.

Coming from
outside the UK

Send the CT and bronchoscopy images and reports. Dr Okiror reads the images himself, a video consultation follows within 48 hours of their arrival, and a written opinion within 48 hours of the consultation. Where treatment is advised, the bronchoscopy and the treatment are usually done under one anaesthetic in a single visit to London, with a written package quote before you travel. The international patients page sets out the two routes to a decision, letters of guarantee for sponsored patients, and when you can travel home.

Send the scans.
The decision is made on them.

Appointments within 2–3 days at London Bridge Hospital, by video within 48 hours of your scans arriving. Self-referrals welcome. Dr Okiror reviews the CT and bronchoscopy images himself and tells you what can be done and what cannot.

Jo Mitchelson, PA  · 020 7952 2882 · pa@lungsurgeon.co.uk

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